Coworker and Patient Harm (Title edited)

CelticGoddess, BSN, RN · Aug 30, 2017

Its ok....Ive never made a med error that resulted in death but it does happen....remember you ALWAYS ALWAYS check TWICE with other nurses or even a head nurse....he may get in to trouble...he probably wont get another job now...unfortunately nurses are the most trusted of professions and when we mess up like that it shows....

Maybe a student needs to check twice with the instructor or other nurses but no way would I have time to check with the other nurses (and no way would they have time to check either) about meds. we had meds that needed a co-signature (chemo, blood, heparin gtts, insulin, insulin gtts, etc) but it's just not possible for a double check every med pass.

I assume you are still a student: things are much different for nurses than it is for students. Errors do happen and they have can happen with double checks. And that is why the five "rights" are so important. You can minimize the errors, but they won't go away completely and you need to take ownership of any errors you make.

LadysSolo · Aug 30, 2017

I caught a serious chemotherapy overdose sent from pharmacy (always do your own calculations!), med was not given, I doubt anything was ever done. Had I given it, it could have been life-threatening. How many people give what pharmacy sends without questioning....... We are all one med pass away from a serious incident - it can happen to anyone. No one can be "holier than thou."

Been there,done that, ASN, RN · Aug 30, 2017

I caught a serious chemotherapy overdose sent from pharmacy (always do your own calculations!), med was not given, I doubt anything was ever done. Had I given it, it could have been life-threatening. How many people give what pharmacy sends without questioning....... We are all one med pass away from a serious incident - it can happen to anyone. No one can be "holier than thou."

Well done. We rely on pharmacy as the first check after a doctor order. Bottom line is... the one who administers the medication is responsible for everything.

Not_A_Hat_Person, RN · Aug 30, 2017

At my last LTC job, I came across a very wrong morphine order. It was transcribed by someone with very bad handwriting who mixed up milliliters and milligrams. It was also calculated for 1 mg/ml, and the stuff we had was 20 mg/ml. The resident had gotten whopping overdoses of morphine for at least a day. She was on hospice, but that didn't mean we were allowed to kill her.

I told the the charge nurse. She looked at me like I was speaking a foreign language. Twenty minutes later, the evening supervisor approached me in the hallway and yelled at me for daring to question an order. Apparently, we're supposed to assume that the pharmacy sent the right thing.

Twenty minutes after that, I walked into the nurses' office and saw the charge nurse and the evening supervisor on the phone with hospice and the resident's family. The charge nurse had done the math, came to the same conclusion I had, and talked to the evening supervisor.

The resident died a few days later. I was gone within a week. I will sell my body on the street before I work in another SNF.

Ruby Vee, BSN · Aug 30, 2017

Recently, a coworker of mine killed a patient. Not on purpose, the MAR was handwritten and he didn't see the decimal point. The patient coded and ended up needing compressions. He was taken to the ER and ended up brain dead as a result. He's a relatively new nurse. I know the state was called and they showed up, but they didn't come to my unit so I don't know what they were looking for. I've made a med error before but not one that caused injury or death, gave it at the wrong time, but it was the right med so nothing ever came from it but it was still scary and woke me up. All my coworkers have made a small med error at least once, but not one that has ever harmed anyone. What happens when a nurse kills someone? Do they lose their licence? We all know what happened but since it was so serious none of the administration will openly address it with us, like they think if they don't talk about it that it will go away. But I'm still curious to know, do they suspend your licence or do they take it? This is why I hate handwritten Mars. My coworker got fired so it's not like I can ask him, and I probably wouldn't anyways because I don't know him that well.

WOW! Drama much?

Your colleague made a med error. It was a humungous, horrible, devastating and in the end, fatal drug error, but that's what it was.

What will happen to your colleague -- none of us knows. It depends upon a lot of factors, none of which we are privy to and most of which you aren't either. I'm sorry he lost his job, especially if this was his first error.

Many of us used hand-written MARs for decades without making an error that resulted in harm to a patient. It is sad that he didn't see the decimal point, but even more sad that he didn't know the correct dosage of the drug he was giving.

allnurses Guide · Aug 30, 2017

My coworker gave a child 10x the indicated dose of epinephrine. Baby recovered, but I'll never forget the look of panic on his (the nurse) face during the incident. He wasn't terminated. Whatever else may have happened is none of my business.

Then there was the person who gave the dad's allergy shot to his son who had just started his treatment. Since I wasn't present at the time, I can't confirm the details. At the time, the procedure was for the patient to examine the label and verify that is his/her serum in addition to the usual nursing checklist.

I once gave a dose of prednisone hours early, due to a new order I was unaware of. My nurse manager guided me through the process and handed me the incident report paperwork, but her attitude was matter-of-fact. I never thought of it as being "written up". Things have really changed.

bellini · Aug 30, 2017

WOW! Drama much?
Your colleague made a med error. It was a humungous, horrible, devastating and in the end, fatal drug error, but that's what it was.
What will happen to your colleague -- none of us knows. It depends upon a lot of factors, none of which we are privy to and most of which you aren't either. I'm sorry he lost his job, especially if this was his first error.
Many of us used hand-written MARs for decades without making an error that resulted in harm to a patient. It is sad that he didn't see the decimal point, but even more sad that he didn't know the correct dosage of the drug he was giving.

Agree. The current safety culture dogma greatly underestimates, if not outright ignores, the importance of nursing knowledge.

JKL33 · Aug 30, 2017

Agree. The current safety culture dogma greatly underestimates, if not outright ignores, the importance of nursing knowledge.

In some places the prevailing "safety culture" wisdom is that the need for human critical thinking is where the opportunity for error arises, so we must do all we can do eliminate that need. One of the more sad and shocking things I've heard straight from the horse's mouth in the last several years.

Miss.LeoRN · Aug 30, 2017

This is a terrible, terrible story, but the fault is with your co-worker. He should have been able to identify that the dose was wrong. Even if he missed the decimal, he should have paused and gone "wait... am I really supposed to give this much?"

Sure, hand written MAR's suck, I facility I work uses hand written MAR's. They attempt to write them as clear as possible, but sometimes they get sloppy, they write illegible cursive, or they use short hand and forget to write down the full details. However, I know that I am still responsible for what I give my patient. Last night it wasn't unusual for me to see "XARELTO 1 tab BID". First, I didn't know that little T with a dot above it was short hand for 1, second it doesn't list the dose. What if pharmacy sent the wrong dose? I also had no idea that Xarelto was actually Rivaroxaban. Our nursing program told us to never bother with brand names, we didn't need to know them. So I never bothered to pay attention to them thinking just that. The "bingo cards" that the meds are on, have all generic names as well. I ran into several MAR's last night that had brand names on them, not the generic. It was my job as the nurse to double check all of them to ensure I was giving the correct medication. Being a new nurse myself, I make it a point to triple check EVERYTHING and if I have a question, or something doesn't look right, I ask another nurse. In a case like this, I lock my cart and walk back to the front desk grab the patient's chart and then look up the actual order, then amend the MAR. If it wouldn't have been in there, I would have had to call the DR to clarify the order.

kbrn2002, ADN, RN · Aug 31, 2017

WOW! Drama much?
Your colleague made a med error. It was a humungous, horrible, devastating and in the end, fatal drug error, but that's what it was.
What will happen to your colleague -- none of us knows. It depends upon a lot of factors, none of which we are privy to and most of which you aren't either. I'm sorry he lost his job, especially if this was his first error.
Many of us used hand-written MARs for decades without making an error that resulted in harm to a patient. It is sad that he didn't see the decimal point, but even more sad that he didn't know the correct dosage of the drug he was giving.

Exactly what I was thinking. If indeed an overdose of this med was responsible for the patients death, why on earth wouldn't the nurse that gave the med question a 10x more than a usual dose before giving it?

Trauma Columnist · Sep 1, 2017

Multiple off topic posts have been removed - please keep to the topic at hand.